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Understand diagnostic and treatment algorithms to make appropriate dispositions for patients suspected of having an ectopic pregnancy. Patients at greatest risk for developing an ectopic pregnancy are those with anatomic abnormalities impairing the ability of a fertilized egg to implant in the uterus.
Symptoms of an ectopic pregnancy develop as the fetus grows by distorting surrounding tissue or rupturing causing peritoneal irritation. In one study, only 10% of physicians were able to identify the presence of less than 400cc of free intraperitoneal fluid, suggesting that a positive FAST typically indicates a large amount of acute blood loss. All women of childbearing age presenting to the ED with abdominal or pelvic pain should have a urine pregnancy test performed immediately on arrival. Stable patients in the first trimester of pregnancy with abdominal pain and vaginal bleeding can be further evaluated in the ED.
The earliest sign of an IUP by transvaginal ultrasound is the double decidual sac sign (click on Figure to the left), occurring at around 4.5-5 weeks after the last menstrual period (LMP).
The β-hCG is a glycoprotein hormone produced by trophoblasts that doubles approximately every 48-72 hours in the first trimester. Although rarely used since the advent of ultrasound, culdocentesis is a simple, bedside procedure that can be performed when ultrasonography is not rapidly available on a potentially unstable patient to detect the presence of intraperitoneal blood. Any patient strongly suspected of having an ectopic pregnancy needs to be medically or surgically managed in conjunction with OB-GYN. Methotrexate is the most successful method to medically manage a patient with ectopic pregnancy and may preserve fertility better than surgical interventions.
All patients suspected of having an ectopic pregnancy are managed in conjunction with OB-GYN.
The presentation of ectopic pregnancy can be highly variable, so maintaining a high index of suspicion is paramount to making the diagnosis. Serum β-hCG values should not be used to determine which patients should have transvaginal ultrasound. An ectopic pregnancy can be 'ruled out' in the presence of an IUP in a patient not undergoing infertility treatment.
Ectopic pregnancy is managed surgically in cases of clinical instability, contraindications to medical therapy, or failure of medical therapy. Any patient discharged from the ED with a potential ectopic pregnancy should understand "ectopic precautions" and have the means to return immediately to the ED. Now that your bump is starting to show, you may be wondering what you can do to keep your weight in check and what kind of exercise is sensible. Tenderness: Your breasts and abdomen may be especially tender during these first few weeks of pregnancy. Stress relief: You probably have a lot on your mind, from choosing a name for your baby to finding the right doctor to picking out colors for the nursery.
Ectopic pregnancy is defined as any pregnancy implanted outside the uterus, with approximately 97% occurring in the fallopian tube. Tubal factors including history of salpingitis, tubal surgery, and previous ectopic pregnancy are the most important risk factors for ectopic pregnancy. The classic triad of abdominal pain, delayed menses, and vaginal bleeding is neither sensitive nor specific for ectopic pregnancy.
A pregnancy test should be obtained on all female patients of childbearing age (consider ages 10-60) who present to the ED with complaint of abdominal pain, amenorrhea, or vaginal bleeding. The combination of positive FAST and positive pregnancy test should prompt an immediate call to OB-GYN to take the patient to the OR for a presumptive diagnosis of ruptured ectopic pregnancy. If you have a strong suspicion of pregnancy and the patient provides a dilute urine, a serum pregnancy test should be considered.
A transvaginal ultrasound should be obtained to evaluate for the presence or absence of an IUP.
A yolk sac (click the Figure just below the one to the left) is typically identified at 5-6 weeks and the presence of a yolk sac has 100% predictive value for an intrauterine pregnancy. The likelihood of finding a live extrauterine embryo with positive heart motion using ultrasound is only 8-26%.
Diagnosis and management of ectopic pregnancy using bedside transvaginal ultrasonography in the ED: a 2-year experience.
Clinical Policy: Critical issues in the initial evaluiation and mananagement of patients presenting to the emergency department in early pregnancy. All her cells have been directed to their places—brain tissue is growing rapidly, muscles are forming, fingers and toes are becoming defined.
Wild highs and truly horrendous lows, sudden mood swings, and crazy behavior are typical during pregnancy. Many pregnant women spend the first few months so exhausted they can barely hold their heads up. The answer is different for every woman, but by listening to your body and not exerting yourself too much, exercising will not only help you feel good but prepare your body for the biggest workout of all—labor and delivery!
In some women the increased level of progesterone has a numbing effect—almost like a sedative. A hormone called relaxin is released into your body to help loosen and stretch your ligaments. Make sure when you exercise to have supportive undergarments—in other words, time to buy a good bra! Exercising can tone and strengthen your muscles, helping you ward off some of these pregnancy pains. What was once this theoretical being allegedly growing inside the body of the woman you love is now more real than ever before.
Learning you are about to become a dad can definitely be incredible, but being able to see your baby for the first time—having that image in your head every time you think about your new baby—truly brings something special to your fledgling relationship.
Being able to walk home with an ultrasound image of your growing baby-to-be can be a big boost in building that new special relationship with your child. It is a life threatening condition complicating 1 in 80 pregnancies presenting to emergency departments. It is important to recognize that many ectopic pregnancies occur in women without any recognized risk factors, so maintaining a high index of suspicion is paramount to making an accurate diagnosis.
Symptoms and physical findings are highly variable among patients, making the diagnosis extremely challenging. If an IUP is visualized, a concurrent ectopic pregnancy (heterotopic pregnancy) is statistically unlikely unless the patient has received fertility treatments. An ectopic pregnancy cannot be excluded until the patient has a yolk sac demonstrated within the gestational sac. ACEP's clinical policy on patients presenting to the ED in early pregnancy states that a transvaginal ultrasound should be performed on all patients in whom the diagnosis of ectopic pregnancy is considered despite the β-hCG level, as both IUP's and ruptured ectopics have been diagnosed at very low levels.
Ultrasound signs of an ectopic include an empty uterus, extraovarian mass, tubal ring sign (click Figure to the left), and pelvic free fluid. Greater than 2ml of nonclotting blood is suggestive of hemoperitoneum and ruptured ectopic pregnancy.
Patients with significant pain without signs of rupture should be admitted for close observation and serial reassessments. Some of this is due to hormones, and some of it is because this is, truly, a very emotional time! In addition, your body’s blood volume increases to deliver nutrients to your developing baby. You may have to put your normal exercise routine off indefinitely in favor of light workouts if you’re suffering from frequent nausea. As your baby grows, it’s important that your body is flexible enough to accommodate her.
If a technician or doctor does express a problem, don’t hesitate to insist on attending. Abdominal pain is the most common symptom and is reported in as many as 98.6% of patients, but its severity and quality is highly variable. This occurs spontaneously at a rate of only 1 in 10,000 pregnancies, but the incidence is much higher for women using infertility drugs or assisted reproductive technologies .
An ectopic pregnancy is highly likely in patients with a β-hCG level greater than 1500 with the absence of intrauterine pregnancy on transvaginal ultrasound. It works by interfering with syntheses of DNA and cell replication of fetal cells, resulting in involution of the pregnancy. Clinically stable patients with an ectopic pregnancy may be managed medically with methotrexate if they have an excellent follow up plan. Later, in labor, your muscles and ligaments will have to stretch even more so that your baby can make her first appearance. You can see whether your little one is moving or not, and you can even begin to imagine the personality he or she might display after birth.
Both your baby and your partner need you there, and seeing your little one for the very first time is a remarkable event. Despite the improved diagnostic modalities, ectopic pregnancy is still frequently misdiagnosed on initial presentation with up to 40-50% of patients correctly diagnosed on repeat visits.
Amenorrhea is present in almost 75% of women with ectopic pregnancies, and irregular vaginal bleeding occurs in 56.4%, but may be minimal even in the critically ill patient. Treatment failure with single dose methotrexate occurs in up to 36% of patients necessitating administration of a second dose of methotrexate if β-hCG values are not decreasing as expected. For those hemodynamically stable patients with inconclusive ultrasound findings where the diagnosis is in doubt, they may be managed as an outpatient with serial ultrasound examinations and β-hCG levels.
Baby also has eyelids—but the bottom and top halves have fused together and will keep the eyes shut for several more weeks, like a kitten’s. Overall, it accounts for about 9% of all pregnancy-related maternal deaths, and is one of the leading causes of maternal death in the first trimester. Tenderness on pelvic exam is the most common physical exam finding, but few patients will have a palpable pelvic mass.
Contraindications for receiving methotrexate include hemodynamic instability, inability to return for follow-up, breastfeeding, immunodeficiency, renal, liver or pulmonary disease, peptic ulcer disease, and blood dyscrasias. Ears, which (oddly) began developing on the neck, are moving into their normal place on the sides of the head. Early diagnosis and treatment is essential in reducing maternal mortality and preserving future fertility. The diagnosis of ectopic pregnancy should be considered in female patients presenting to the ED with syncope or unexplained hypotension. All patients discharged from the ED who have the potential to have an ectopic pregnancy must receive and understand the "ectopic precautions" and be instructed to return to the ED immediately if they develop worsening pain, vaginal bleeding, dizziness, syncope, or weakness. The baby can now swallow amniotic fluid and its life-sustaining organs (think heart, brain, liver, kidneys, intestines) are beginning to work.
The majority of patients with an ectopic pregnancy have normal vital signs until they have experienced significant blood loss.
Paradoxic bradycardia can occur in ectopic pregnancy, thus vital signs should not be reassuring and all patients with ectopic pregnancy should be considered potentially unstable.
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